**Aggregate - Group of people who share a common aspect (age, economic status, cultural background, gender, area of residence, or chronic illness.

Client

– Individual, family, group or community.

Community

– Interactions among groups of people with common bonds and environment.

**Community-based nursing

– Focus is on the individual - Care of the acute or chronically ill person and their family Focus is to promote self-care, decision making and autonomy.

**Community health nursing – Focus is on health of the community –

Here professional nursing merges with knowledge of public health sciences.

Changing Times: Health Care Reform

Americans are living shorter and less healthy lives than people in other industrialized countries.

Forces have led to a situation where health care costs have become out of control and people have become increasingly dissatisfied with the care available. Forces (factors) affecting change include demographics, social forces, economics, technology and health care delivery.

HMOs (Health Maintenance Organizations) were founded as an alternative to private insurance.

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A Prospective payment system was enacted for health care services based on federally mandated diagnosis-related groups (DRGs) in 1982 and 1983. Hospitals therefore began receiving one **lump fee for a diagnosis.

This fundamental change in the payment process paved the way for the shift from hospital to community-based care.

Healthy People 2000: National Health Promotion and Disease Prevention - is a publication (report) on the health status of Americans that was prepared by the Department of Health & Human Services.

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The three main goals of Healthy People 2000 include: Increasing the span of healthy life, reducing health disparities among populations, and achieving access to preventive services for all Americans.

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The three main areas of focus of Healthy People 2000 include illness prevention, health promotion and health protection.

Health Care Refocused

Hospitals are declining in use and importance as health care moves to a community-based system with focus on wellness, prevention and cost-effectiveness.

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To position themselves for the new direction of the health care industry, large hospitals are buying up small hospitals, home health agencies, laboratories, clinics, nursing homes, rehab centers and medical practices to create networks of care.

The health care delivery system is changing dramatically in response to tighter resources and greater health demands. The number of home health care agencies, stand-alone clinics, and rehabilitation centers is growing rapidly.

The major components of the new health care delivery system are primary prevention, disease control, maintenance of chronic conditions, and cost-effectiveness (as well as elimination of environmental hazards and individual responsibility for health related behaviors.

Clients admitted to hospitals today to receive critical, intense medical treatment, stays are short and recovery takes place in the community (not in the hospital) with family assuming much of the care once carried out by the nurse.

Implications of Health Care Reform for Health Care Education

The PEW Health Professions Commission (in 1993) published Health Professions Education for the Future: Schools in service to the Nation that challenged current education & stated a need for change (thus ‘reform’ with the rest of the health care system).

The PEW Commission established competencies for health care professionals that include the practice of prevention, ensuring cost-effective and appropriate care, and caring for the community’s health.

Specific Implications for Nursing Education

Health care emphasis is on the family, aggregate, and community levels. The goal of the nurse in the community is to keep clients at functional levels of wellness.

The NLN (National League for Nursing) has charged basic nursing education programs with implementing reforms to ensure graduates across all programs are competent to function in community-based health care settings.

To practice in today’s health delivery system, a nurse must receive instruction in community-based care.

Community-Based Nursing

As defined earlier, takes place where the clients live, work and play. It may be a school, work site, camp, American Indian reservation, home, or migrant workers’ camp

The individual & family have primary responsibility for their health care decisions.

The philosophy related to CBN is the human ecological model, which describes human development throughout the course of life.

Example: The inner circle beings the individual/immediate family à
extending out to the next circle, friends, neighbors, co-workers & extended family à
then out to local church & community à
and the farthest circle involving the state & national government, and church denomination

Community-Based Nursing versus Community Health Nursing

Review as defined earlier and understand that community-based nursing is for the purpose of safeguarding & improving the health of populations.

It is based on the principals of social justice, that everyone is entitled to basic necessities such as adequate income and health care.

Also known as public health nursing, and is the art & science of preventing disease, prolonging life, promoting health & efficiency through organized efforts (Efforts are supported by federal, state and local government, with state & government mostly providing advice or support). Local levels provide protection services related to sanitation, air, water pollution control & personal health (i.e. immunizations).

The nurse is the major health care professional on this team!

Community Health nurses use a population-focused approach, and this focus is concerned with aggregates (groups of people with common or similar problems that can be very broad or specific). They care for the community as a whole & consider the person or family to be only one member of a group at risk.